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Abstract
Background The electronic nicotine delivery system (ENDS) JUUL has quickly captured the ENDS market, representing 74.6% of the total dollar share for this category as of November 2018. Although JUUL is marketed as an alternative to cigarettes intended for current adult smokers, evidence suggests that a majority of ENDS users are concurrently current cigarette smokers. Little is known about the dual use of JUUL and cigarettes, as well as the reasons for trying JUUL among adult tobacco users.
Methods A survey fielded via web and phone of 1332 current cigarette, cigar, little cigar or cigarillo (CLCC), and ENDS users aged 18–54 years was conducted from March to May 2018. Weighted descriptive and bivariate analyses examined JUUL use and reasons for trying JUUL by demographics, combustible tobacco use, ENDS use and intention to quit.
Results Approximately 81% of our sample reported current use of two or more tobacco products, including cigarettes, CLCCs or ENDS. Among current tobacco users, 15% ever used JUUL and 12% used JUUL in the past 30 days. Most individuals (74%) reporting ever JUUL use indicated using it for 5 days or fewer in the past 30 days. The most common reason for trying JUUL was trying to quit smoking cigarettes (37%), followed by family, friends or colleagues using the product (32%).
Conclusion Although some tobacco users may be initiating JUUL to decrease combustible use, most were using the product infrequently and concurrently with other products. Findings have significant implications for cessation intervention efforts and policy development to help smokers quit.
- electronic nicotine delivery devices
- cessation
- non-cigarette tobacco products
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Introduction
According recent surveys, 15.3% of US adults have tried an electronic nicotine delivery system (ENDS) product and 3.2% are current users.1 2 Between 59% and 70% of current ENDS users are also current cigarette smokers, and dual use is common among both youth and adult tobacco users.3–5 Reasons for initiating ENDS include curiosity, cost, perceived relative safety compared with combustibles, evading smoke-free policies, minimising secondhand smoke exposure and mitigating tobacco withdrawal during quit attempts.6–10 Some studies suggest that ENDS may help smokers quit11–16; however, there is limited evidence that ENDS can be an effective cessation aid.17 Importantly, only exclusively switching from combustible tobacco to ENDS can reduce users’ exposure to toxins and carcinogens in cigarettes.17
Introduced in 2015, JUUL is an ENDS device that uses disposable e-liquid pods containing nicotine salts to deliver high concentrations of nicotine.18 After increased Food and Drug Adminsitration (FDA) scrutiny due to JUUL’s initial youth-appealing marketing,19–21 JUUL currently markets itself as a tool to help smokers switch from combustible products. JUUL has not been approved as nicotine replacement therapy, however, due to insufficient research on its cessation efficacy. By April 2019, JUUL comprised 74.6% of the ENDS market,22 calling into question the reasons for its use since recent evidence suggests youth and young adults are JUUL’s primary consumers.23 24 This paper examines the dual use of JUUL among current adult tobacco users and explores the reasons for JUUL initiation.
Methods
Sample
Participants (n=1332) were current (1) cigarette, (2) cigar, little cigar or cigarillo (CLCC), and/or (3) ENDS users (‘tobacco users’). Data were collected from March to May 2018. Participants were English-speaking or Spanish-speaking adults, 18–54 years old and drawn from the probability-based, nationally representative NORC AmeriSpeak Panel (n=1002).25 To ensure adequate sample size of tobacco users, additional data were collected through an online non-probability-based panel from Survey Sampling International (SSI) (n=330). See online supplementary table 1 for demographic differences between probability and non-probability samples. Eligible SSI respondents were either current or never users aged 18–24 years or tobacco users aged 25–54 years. This study was exempt from institutional review board (IRB) review (Advarra IRB protocol number: Pro00024529).
Supplemental material
Panellists were asked demographic and tobacco use questions online or via telephone and then completed supplemental online surveys, where they were shown pictures of JUUL and were asked about product use.
Measures
Study demographics included age (18–24, 25–34 and 35–54 years), race/ethnicity (white non-Hispanic, black non-Hispanic, other non-Hispanic or Hispanic), gender (male or female), education (no high school diploma, high school, some college, Bachelor of Arts (BA) or above), employment status (working or not working) and perceived health status (excellent, very good, good, fair or poor). Intention to quit among current cigarette smokers was measured by the question ‘Are you planning to stop smoking cigarettes within the next 30 days?’
Ever use was defined as ‘even one or two puffs’ for cigarettes, CLCCs, ENDS and JUUL separately. ENDS were defined as ‘e-cigarettes, e-cigs, vape pens, vape tanks, JUUL devices, hookah pens or e-hookahs’. Across tobacco products, everyday and someday users were considered current users. Ever JUUL users were also asked, ‘During the past 30 days, on how many days did you use a JUUL e-cigarette?’ JUUL users were also asked, ‘Do you now use the JUUL e-cigarette every day, some days or not at all?’ Although major national population-based surveys have yet to include items on JUUL, these adapted questions correspond to previously validated e-cigarette measures.4
Ever JUUL users were asked, ‘Which of the following were reasons that you tried JUUL?’ Multiple-choice options included ‘I was trying to quit smoking cigarettes’, ‘I heard JUUL had strong nicotine content’, ‘I heard JUUL had appealing flavours’, ‘I thought JUUL had an interesting product design’, ‘My family, friends or colleagues were using it’ (peer influence) and ‘Other (specify)’.
Analysis
Analyses were conducted in Stata/SE V.15.1.26 Poststratification weights calibrating the overall sample were used to offset non-response bias and to produce nationally representative estimates of US adult smokers.27–29 Weighted descriptive and bivariate analyses were conducted to examine JUUL use and reasons for trying JUUL by demographics, tobacco use and intention to quit. χ2 tests were used to examine differences in demographic and smoking-related variables by JUUL use status.
Results
Among all current tobacco users, 22% reported everyday e-cigarette use, 33% reported someday e-cigarette use and 45% did not use e-cigarettes in the past 30 days. Among all current tobacco users, 15% ever used JUUL and 12% used JUUL in the past 30 days (online supplementary table 2). Among 55% of the sample who were current ENDS users, 29% reported ever JUUL use and 27% used JUUL in the past 30 days. Of ever JUUL users, over half used JUUL 1–2 of the past 30 days (35%) or 3–5 of the past 30 days (21%). Roughly one-quarter used JUUL for 10 or more days (22%), and only 4% of ever JUUL users used JUUL on each of the past 30 days.
Supplemental material
Demographics of JUUL use
In bivariate analyses, both tobacco users aged 18–24 years (23%) and 25–34 years (25%) had higher ever past 30-day JUUL use rates versus tobacco users aged 35–54 years (3%, p<0.001). Men (15%) had higher past 30-day JUUL use rates than women (9%, p=0.014). Those intending to quit smoking (21%) reported higher past 30-day JUUL use rates versus those not planning to quit (8%, p=0.002) (online supplementary table 2).
Multiple tobacco product use
Most participants currently used two or more tobacco products, including cigarettes, ENDS or CLCCs (81%). Among current ENDS users, 73.2% were current cigarette smokers and 50.7% were current CLCC users; only 3.2% exclusively used ENDS. Among ever JUUL users, 47% indicated daily CLCC use, and 14% reported CLCC use on some days. There were no statistically significant differences in frequency of cigarette use among ever JUUL users. Current other tobacco product use patterns were similar for past 30-day JUUL use (online supplementary table 1).
Reasons for first trying JUUL
Among ever JUUL users, the most frequent reason for first trying JUUL was ‘I was trying to quit smoking cigarettes’ (37%), followed by peer influence (32%) (table 1). Daily cigarette smokers (50%, p=0.015), daily CLCC users (59%, p=0.024) and those attempting cessation (60%, p=0.008) reported trying JUUL to quit smoking cigarettes at a higher rate compared with someday or non-current users or those who did not plan to quit. Peer influence was reported more often among non-current cigarette users (70%, p=0.019) and non-current CLCC users (79%, p<0.001). First trying JUUL because of its flavours was more frequently reported among daily CLCC users (41%, p=0.028) and those intending to quit (43%, p=0.015). First trying JUUL for its high nicotine content was more common among men (33%, p=0.024), daily cigarette users (33%, p=0.044), daily ENDS users (40%, p=0.030) and daily LCC users (41%, p=0.040).
Reasons for first trying JUUL among tobacco users aged 18–54 years who had ever used JUUL (n=263)
Discussion
Results from this study are consistent with previous research indicating ENDS use is more popular among younger populations.1 30 Our results underline JUUL’s popularity among young adults, with approximately one-quarter of tobacco users aged 18–34 years reporting past 30-day JUUL use compared with 3% of tobacco users aged 35–54 years. These findings undermine JUUL’s stated goal of switching cigarette smokers to JUUL, since only 20% of our current tobacco users aged 18–24 years indicated that they first initiated JUUL to quit. Further, rates of ever and past 30-day JUUL use were similar, suggesting that users may transition from experimental to sustained use, though longitudinal research is needed to fully understand this relationship.23 These findings are consistent with literature on reasons for youth ENDS experimentation and reinforce the need for strong regulatory action to prevent use by those least likely to report first use for cessation.31
While over one-third of current tobacco users tried JUUL to quit smoking cigarettes, the majority are dual users who use ENDS simultaneously. Beyond JUUL, of all current ENDS users, nearly three-quarters also currently smoked cigarettes, suggesting that dual use rates may be even higher than previous population surveys indicated.3 4 This may be reflective of the evolving ENDS landscape and increasing use prevalence.3 Although dual use may be antecedent to cessation, data are limited on whether dual users completely switch; more longitudinal research is needed to understand the complex relationship between cigarette and ENDS use.15 32 Additionally, although 37% of tobacco users indicated trying JUUL for cessation, over half of current tobacco users reported JUUL use on only 1–5 days a month. Since ENDS are most effective at aiding cessation when used frequently,17 occasional JUUL use among tobacco users is likely insufficient to achieve cessation. To facilitate quitting, evidence-based approaches are necessary and healthcare providers should counsel patients to use FDA-approved products.33 Current smokers should also be informed that only completely switching to ENDS is beneficial, since even light or intermittent cigarette use is related to higher mortality risks.34
This study has limitations, including the inability to discern whether tobacco users successfully used JUUL to quit combustibles. It also did not assess if JUUL was used for cessation and only surveyed current tobacco users, potentially missing former tobacco users. The study is also limited by the use of an online panel, as well as a non-probability-based supplement, since non-internet users may be excluded; however, these panels have been used in previous research and weighting procedures mitigate potential biases.28 Notwithstanding these limitations, our study provides information on patterns of dual use of JUUL with other combustible tobacco and indicates that reasons for initiation do not match JUUL’s ‘switching’ market focus. Although these analyses are cross-sectional, they provide insight into reasons for JUUL use since most users did not report JUUL initiation for cigarette cessation. Future studies must capture how JUUL and similar products are used for cessation. Given the high rates of JUUL use among young adults, our findings further reinforce the need for federal oversight of this currently unregulated product.
What this paper adds
What is already known on this subject
Although frequent use of electronic nicotine delivery system (ENDS) is associated with increased likelihood for smoking cessation, there is inconclusive evidence that ENDS can effectively help smokers quit.
JUUL, the most popular ENDS currently on the market, has marketed itself as a product intended to help smokers switch.
What important gaps in knowledge exist on this topic
Dual use of JUUL and other tobacco products, as well as reasons for initiation among adult tobacco users, is unknown.
What this study adds
Only one-third of tobacco users are trying JUUL because they are trying to quit smoking, followed closely by friends and family influencing use.
Due to the largely inconsistent use of JUUL, tobacco users may not be able to successfully quit smoking by using this product.
References
Footnotes
Contributors MP and AC conceptualised and wrote the paper. YZ contributed to the study design, analysis and revisions. DV, ECH, BS and JW contributed to the conceptualisation. LC and ECK contributed to the writing and revision of the manuscript. All authors reviewed and revised the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.